Chevron Business Card Application

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Chevron Business Card Application Powered By Docstoc
					Chevron Business Card Application
FAX Application toll-free to: 1-888-839-0012 or
Mail to: FleetCor Commercial Card Management (Canada) Ltd., PO Box 921729, Norcross, GA 30010-1729, USA                                                                         For more information call toll-free: 1-888-243-8358
Application for Canadian businesses only. US businesses, please visit www.ChevronTexacoBusinessCard.com.
All fields must be completed to help ensure timely processing. PLEASE PRINT, USING BLACK INK.
BUSINESS INFORMATION – PLEASE TELL US ABOUT YOUR BUSINESS

 1     Business Legal Name (or if Sole Proprietorship, Owner Name)                                              (Required) Federal Tax ID or (Optional) SIN #
                                                                                                                Business Structure/Type
                                                                     –                –                         K Corporation                             K Proprietorship                 K Not-for-Profit*
                                                                                                                K Government                              K ULC          K LLP             K Partnership           K LP
       $
       Credit Limit Requested                         Fax Number                                                *Please attach tax exemption certificate. (A fee may apply.)




       Physical Address Line 1 (No P.O. Boxes)                                                                                                            Years under current ownership


                                                                                                                                                      $
       Physical Address Line 2 (No P.O. Boxes)                                                                                                            Annual Sales Volume (Dollars)

                                                                                                                                     –
       Physical Address City                                                                       Province         Postal Code



       Mailing Address Line 1 (if different from Physical Address)


                                                                                                                                     –
       Mailing Address City                                                                        Province         Postal Code

CONTACT INFORMATION – PLEASE TELL US ABOUT YOURSELF

 2                   –
       Main Business Phone
                                      –
                                                                 E-mail Address For Online Statements and Reports



       Key Executive Title                              Key Executive First Name                                                Key Executive Last Name


                                                                                                                      –                     –                            ext.
       Billing Contact’s First Name                     Billing Contact’s Last Name                     Billing Contact’s Phone Number

                     –                –
       Cell Phone/Secondary Number                               Choose security password to be used for Account Access (minimum of four characters).

       How would you like to receive your statement? (check one)                              K Online        K Paper*
       *A fee may apply.
FINANCIAL/REFERENCE INFORMATION – PLEASE TELL US ABOUT YOUR BUSINESS BANKING AND REFERENCES

 3     Bank Reference (Primary)
                                                                                                  –
                                                                                      Bank Phone Number
                                                                                                                 –
                                                                                                                                                   Bank Account Number


                                                                                                  –              –                                                   –                 –
       Trade Reference Name                                                           Trade Reference Phone Number                                Trade Reference Fax Number


                                                                                                                                                                     –                 –
       Current Fuel Supplier                                                          Account Number                                              Fuel Supplier Phone Number
 SET-UP INFORMATION – PLEASE TELL US HOW YOU WOULD LIKE YOUR ACCOUNT SET UP

 4     1. Choose Type of Cards

                                Number of Driver Cards                                                                      Number of On-Site Station Cards
                                                                                                              Facility/Station # for On-Site Station Cards. See station manager
                                Number of Vehicle Cards
                                                                                                              for more information. Issued upon station validation.

       2. If you choose to have Driver Cards, please fill out this section:                                      3. If you choose to have Vehicle Cards, please fill out this section:



       J OHN                                 DOE                                                                 02                 F ORD
       Driver Name (First)                   Driver Name (Last)                                                 Vehicle Name or Vehicle ID #




       Promo Code                                                            Employee Identifier                                                                Site ID                                            Page 1 of 2
Business Name: ______________________________________________

AUTHORIZED SIGNATURE OF CUSTOMER – PLEASE SIGN AND DATE
        PLEASE READ CAREFULLY: FleetCor Commercial Card Management (Canada) Ltd. (“FleetCor”) operates the Chevron Canada commercial card products and this application is made to FleetCor. By signing this application,
 5      Customer hereby (i) confirms that everything it has stated in this application is correct; (ii) agrees that, if this application is approved by FleetCor, then Customer will be bound by the terms and conditions of use which accompany
        the Chevron Canada card(s) (the “Cardmember Agreement”), including, without limitation, Customer’s obligation to pay each billing cycle for all use of such cards as well as all interest, fees and costs associated with such cards
        and account; and (iii) authorizes FleetCor and/or its affiliates to use and disclose the information collected on or in connection with this application to verify Customer's credit references and the information on this application,
        obtain credit reports from and provide credit information to reporting agencies (now or in the future) regarding Customer, periodically update the Customer's credit file, invoice, charge and collect payment for credit advanced,
        perform security and related investigations, determine whether to renew credit facilities from time to time, and otherwise facilitate the provision of credit facilities in accordance with applicable law. FleetCor may store and process
        your information outside Canada, and the laws of other countries regarding the collection, use and disclosure of such information may be different from the laws of Canada. For further information, please see FleetCor’s Privacy
        Policy at www.fleetcor.com.

                                                                                                                                                                                                    /        /
        Print Name (Authorized Representative)                                             Signature (Authorized Representative)                                                              Date (MM/DD/YYYY)
                                                                                           I have authority to bind customer.

PERSONAL INDEMNITY BY PRINCIPAL OF CUSTOMER – PLEASE COMPLETE AND SIGN – May be required for: Corporations Less Than Two Years Old and All Sole Proprietorships, Partnerships and ULC’s.
        PLEASE READ CAREFULLY: By signing below, the undersigned (“Indemnitor”) covenants and agrees with FleetCor (i) to be jointly and severally bound with Customer to FleetCor for the performance of Customer's
 6      obligations under the Cardmember Agreement as a direct and primary obligor and indemnitor, and not merely as a surety; (ii) to at all times indemnify and save FleetCor and its affiliates harmless from and against all
        losses, costs, damages and expenses which any one of them may incur by reason of default by Customer in performing any of its obligations under the Cardmember Agreement; and (iii) that FleetCor may, without
        Indemnitor’s consent, extend time for payment of monies payable under, or vary the terms of, the Cardmember Agreement as determined by FleetCor in its absolute discretion. If Customer defaults under the
        Cardmember Agreement, FleetCor may proceed against Indemnitor as if it were Customer, without waiving any of its rights against Customer, and without first proceeding against Customer or taking recourse to or
        exhausting any of its remedies against Customer or any other security, guarantee or indemnity. This indemnity and all related matters are governed solely by the laws of British Columbia, Canada and applicable federal
        laws of Canada, excluding any rules of private international law or the conflict of laws that would lead to the application of any other laws. Indemnitor acknowledges that FleetCor’s extension of credit to Customer is
        conditional upon receiving this indemnity, and that Indemnitor has received good, valuable and sufficient consideration therefor. Indemnitor authorizes FleetCor and/or its affiliates to use and disclose information collected
        on or in connection with this application to obtain credit reports on Indemnitor periodically, perform security and related investigations, determine whether to renew credit facilities from time to time, and otherwise
        facilitate the provision of credit facilities in accordance with applicable law. If this application is denied based on such information, Indemnitor authorizes FleetCor to report the reason for the denial to Customer. FleetCor
        may store and process your information outside Canada, and the laws of other countries regarding the collection, use and disclosure of such information may be different from the laws of Canada. For further information,
        please see FleetCor’s Privacy Policy at www.fleetcor.com.
                                                                                                                                                                                                    /        /
        Print Name (Indemnitor)                                                           Signature (Indemnitor)                                                                             Date of Birth (MM/DD/YYYY)


        Indemnitor Street Address                                                         City                                                                                               Province          Postal Code


        (Optional) SIN #                                                                  Driver’s License # and Province




         If you are requesting more than 7 cards, please attach a separate sheet with additional card information.
         Include your name, company name, and phone number.

Rev. 03/08                                                                                                                                                                                                                    Page 2 of 2